Dr Henan Dh Skheel 2020 - PowerPoint Presentation

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Dr Henan Dh

Skheel

2020

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Causes of early pregnancy bleeding

1-Miscarriage

2-Ectopic pregnancy3- Molar pregnancy4Local cervical causes

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Spontaneous

miscarrage

Definition•It

is expulsion or extraction of products of conception before fetal viability i.e. before 20

weeks of gestation.

Incidence

:•Is the

commonest gynecological

& obstetric disorder

.About

15% of clinically recognized pregnancies end

in miscarriage(this

rise to 30% if unrecognized pregnancies are included

).

Most miscarriage occur between 8 and 12 weeks of pregnancy.

Early pregnancy loss: If it occurs before 12 weeks (80%) Late pregnancy loss: If it occurs between 13 to 24 weeks (12%) ( usually there is a fetus)

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Early pregnancy loss classified into;

Empty gestational sac: No fetus on U/S examination and fetal tissues absent on histological examination

Early fetal demise: fetus present on U/S examination fetal tissues present on histological examinationFactors influence rate of spontaneous miscarriage:

Maternal age > 35 years

Gravidity

Previous miscarriage

Multiple pregnancies

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Ultrasound Findings of EPL

Anembryonic Pregnancy

— No fetal pole with mean sac diamter >25 mm (

transabdominal) OR >18 mm (transvaginal) or <4 mm growth in 7 days (No yolk sac, with mean sac diameter >25mm)

Embryonic Demise

— No cardiac activity with CRL ≥7mmYolk sac

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Etiology

First trimester miscarriage :Chromosomal abnormalities structural abnormalities and

Gene defects (absence of specific enzyme) 1.Fetal chromosomal abnormalities - particularly trisomy , triploidy & monosomy is the commonest cause of miscarriage 50– 70 % of the first trimester abortions are due to chromosomal abnormalities the incidence of these abnormalities increased with the increase in the

maternal age

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Abnormal

conceptus

Means an empty gestational sac without embryo development. (Blighted ovum ) Most miscarriage occurs before 8 weeks’ gestations. Result from: Error in maternal and/ or paternal meiosis chromosomal division without

cytoplasmic divisionThe chromosomal abnormalities include;

♣ Autosomal trisomy; The non-disjunction defect is found approximately in 60% of blighted ovum with abnormal karyotypes,most non-disjunction occurs during 1st mitotic

division.The

affected chromosomes are: 16 (32%)22 (10%)21 (8%)

♣ Triploidy ; occurs in 12-15% of chromosomal abnormalities double paternal chromosomes (69 chromosomes)partial molar of pregnancy occurs in 5%

♣ Monosomy X; represents 25% of miscarriage with chromosomal abnormalities (45X)

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Structural rearrangement

; the abnormality consists of unbalanced translocation accounts 3-5% of miscarriage with abnormal chromosome 3% of couples will be carrier if karyotyping is required

II- structural abnormalities as Nural tube

deffect (NTD) , uncommon cause of miscarriage III- Gene defect

; -difficult to determine because of facilities to identify the individual gene defects.-Example as

autosomal

dominant disorders and X-linked dominant disorders.

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.

4.Infections

: genital tract infection , systemic infection with pyrexia & TORCH syndrome5.Endocrine

disorders : Diabetes, thyroid disorders , PCOS & corpus luteum insufficiency

6.Uterine

disorders: Uterine anomalies ,submucus fibroid &

Asherman’s

syndrome

8.Thrombophilia: Congenital deficiency of protein C & S, & anti-thrombin III9.Immunological disorders : Anticardiolipin syndrome and SLE

10. Cigarette smoking , anaesthetic agents &chemical agents .

11. Psychological disorders

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Abnormal conceptus

as genetic abnormalities (50-60%),

Etiology:Abnormal conceptus

as genetic abnormalities (50-60%),structural abnormalities (3-5%)Endocrine abnormalities (10- 15%)Cervical incompetence (8-10%)

Uterine anatomic abnormalities 1-3%)

Immunological (5%)Infections

Unknown reasons (< 5%)

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II-

Endocrine causes

*Corpus luteum is essential for maintenance of pregnancy during the first 8 weeks.* Surgical removal of it→ miscarriage within 4- 7 days

* Parenteral progesterone may prevent miscarriage but the evidence of progesterone deficiency as a cause of miscarriage is unsatisfactory.* In the past, progesterone have been used among women with recurrent miscarriage with good results. It is possible that corpus

luteum

deficiency could be a cause of early pregnancy loss.

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-Uterine abnormalities

A- Uterine malformations; Result from a failure of normal fusion of the

Mullerian ducts, as:

bicronuate uterus, septate or subseptate, and uterus

didelphys

. may result in miscarriage B- Intra-uterine

synechiae

( Asher man's syndrome) in which there is either partial or complete adhesion between walls of uterus leading to partial or complete obliteration of the uterine cavity. Usually occur as a result of intrauterine infections following; Retained parts of conception post-

abortal

or postpartum curettage

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Cervical incompetence

Is a well recognized cause of miscarriage in late second trimester

▲ The clinical feature are: - painless cervical dilatation (main presentation) - increase vaginal discharge - speculum examination shows bulging membrane with cervical dilatation

▲Causes; Trauma to cervix is the main etiological factor - vigorous mechanical dilatation of cervix - trauma during delivery - cone biopsy - cervical amputation Congenital; rare

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Infection

◙ uncommon cause of miscarriage◙ acute maternal infections as ;

peyelitis, appendicitis can lead to general toxic illness with high temperature that stimulates the uterine activity → miscarriage.◙ early diagnosis & treatment will control most of infection and forestall the occurrence of miscarriage◙ syphilis can cross the placenta → IUFD and miscarriage◙ other infections as; Rubella, Toxoplasmosis,

Listeriosis, CMV, and Mycoplasma can lead to miscarriage

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Immunological causes

Immunological rejection of fetus can cause recurrent miscarriage may be due to failure of the normal immune response in mother an example is anti-phospholipids antibody syndrome responsible for 3-5% of recurrent miscarriage

OthersToxic factors .Anesthetic gases, smoking, alcohol, and drug abuse can cause miscarriage- Trauma amniocentesis, CVS, IUCDs, and abdominal surgery

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Second trimester miscarriage

:1.Multiple pregnancy

2.Cervical incompetence (congenital & acquired )3.Uterine anomalies and

submucous fibroid4.Genital tract infection and PROM

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Differential diagnosis

1-Ectopic pregnancy

2-Hydatiform mole ( molar pregnancy)3-Local causes as; cervical erosion, cervical polyp, etc.Clinical assessment

History; includes personal history complains as; vaginal bleeding, pain ,medical historyB- Examination* General assessment for any signs of shock* Abdominal examination

for:abdominal

tenderness size of uterus

large

:wrong

date multiple pregnancy molar pregnancy fibroids

smaller :non- viable fetus

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Types of miscarriage

1-Threatened miscarriage

2. Inevitable 3

. Incomplete 4. Complete

5

.

Missed

6

.

Septic7. Recurrent

8-Termination of pregnancy

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Types of miscarriage

1-

Threatened miscarriage .Referred as vaginal bleeding before 24 week’s gestation when there is a viable fetus without evidence of cervical dilatation and pain.

2- Inevitable, if the cervix becomes dilated, the bleeding increases and there is pain. 3- Incomplete, if there is partial expulsion of product of product of conception (usually the fetus) with retention of some parts ( usually placenta). With heavy vaginal bleeding may lead to hypo-

volaemic

shock- lower abdominal pain some times sever-,cervix dilated- Retained parts of conception on U/S examination

4-Complete miscarriage- bleeding minimal- no pain- cervix closed- empty uterus on U/S examination

. 5- Missed miscarriage, the embryo dies in utero but is not passed

6 -Septic, infection may occur following any type of miscarriage and may spread to pelvis or even leads to septicemia.

7-Recurrent miscarriage, referred as three or more consecutive

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Threatened miscarriage

1-History

Mild vaginal bleeding.

No abdominal pain or mild abdominal pain

2.

Examination .Good

general condition

. The

cervix is closed

.the

uterus is usually the correct size for

date

3

. U/S which is essential for the

diagnosis Showed

the presence of fetal heart activity

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Inevitable and incomplete

miscarriage(Features)

History .Heavy vaginal bleeding., with no passage of products conception

(inevitable),with the passage of products of conception (incomplete abortion),Severe lower abdominal pain which follows the bleeding

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If the vaginal bleeding is slight → speculum examination

* Pelvic examination Should be carried out in all cases If the vaginal bleeding is slight → speculum examination for- any vaginal infection- cervical lesion. If the bleeding is heavy → digital examination to assess- cervical tenderness ? Ectopic- state of cervix- any RPOC felt inside cervix should be removed manually ,relieve pain & decrease bleeding

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Serum B-HCG may be required to confirm pregnancy

C- Investigation.

Serum B-HCG may be required to confirm pregnancy.Ultra-sound examination.

Abdominal U/S GS will be seen normally if SBHCG ≥ 3000mIU/mlTrans-vaginal ; more accurate GS will be seen normally if SBHCG ≥ 1500mIU/ml NB; if fetal heart seen on U/S examination, pregnancy will continue in 98%.

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Management Options

.

\Do Nothing: Expectant managementDo Something: Medical managementDo Surgery: Surgical management

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o Nothing: Expectant Management

Overall success rate 81%

Success rates vary by type of miscarriage — Incomplete/inevitable abortion 91% — Embryonic demise 76% — Anembryonic pregnancies 66%

Medical Management Single dose misoprostol 400–800 mcg repeat dose x 1 if incomplete success rate 80–88% at 24 hours. Success rate depends on type of miscarriage — 100% with incomplete abortion — 87% for all others

Requirement for medical Therapy

<13 weeks gestation, stable vital signs ,no evidence of infection, no allergies to medications used

Adequate counseling and patient acceptance of side effects

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Misoprostol

.

Prostoglandin

E1 analogue FDA approved for prevention of gastric ulcers .Used off-label for many Ob/Gyn Indications: —

1- Labor induction (Cervical ripening) .

2-Medical Miscarriage (with

mifepristone

antiprogesteron

)3- Prevention/treatment of postpartum hemorrhage Can be administered by oral,

buccal

, sublingual, vaginal and rectal routes.

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Surgical Management Early Pregnancy Loss

Suction dilation and curettage (D&C)

Who should have surgical management?

Unstable Pt(hypovolemic shock) Significant medical morbidity

Infected(septic miscarriage)

Very heavy bleeding

Anyone who WANTS immediate therapy

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Threatened miscarriage(

Management

)1.Reassurance If fetal heart activity is present, > 90% of cases will be progressed satisfactorily

2.Advice:Decrease physical activity (bed rest is of no therapeutic value) avoid intercourse

3.Hormonesi.e

. Progesterone & hCG Which are used in the first trimester to support pregnancy, (but they are of

no proven

value

)

4.Anti- D:An adequate dose of anti-D should be given to all Rh –ve,non-immunised patients, whose husbands are Rh +

ve

5.ANC

as high risk

patients because

those patients are liable

for late

pregnancy complications such as APH and preterm

labor

.

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Management

2-

Incomplete miscarriage- Assessment of general condition- Blood sample for blood group, RH factor, and CBC- Removal of RPOC if felt in cervical canal- Ergometrine

0.5mg IV or IM to ↓ blood loss Evacuation of uterus UGA followed by gentle curettage - Ergometrine 0.5mg IV will encourage uterine contraction

-Anti D if RH negative

- If there is hypo-

volaemic

shock, may require blood transfusion

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Septic miscarriage

Occurs as a result of ascending infection following miscarriage. If not treated, infection may spread throughout pelvis → septicemia and septic shock Signs; pyrexia abdominal pain, and tenderness persistent vaginal bleeding offensive vaginal discharge

U/S examination for retained parts Treatment

Investigation. routine basic investigations as BL. Group, RH factor, CBC, BS, urea & electrolytes, etcCervical swab/S examination for retained partsT

reatment

. Broad spectrum antibiotic, IV fluids ± blood transfusion if needed ,analgesia, evacuation of uterus and Anti D

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Complications of septic miscarriage

Septicemia, and septic shock

Acute renal failureChronic pelvic infectionInfertility

Missed miscarriage clinical feature: - Disappearance of symptoms of pregnancy-Size of uterus < duration of gestation- U/S shows no signs of fetal life-PT will remains positive as long as the placental tissues survive then become –ve

Treatment: there is no urgency in treating missed miscarriage because: spontaneous miscarriage mostly occurs

coagulation defects(DIC)

due to dead fetus syndrome are rare less 25%

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Induced abortion

Induced abortion is not considered in medical terms alone but it arouses strong personal emotions and involves religious and ethical considerations

. Indications; termination of pregnancy may be medically indicated to safe life of patients as in: malignant diseases of cervix, breast and sever cardiac disease. Also fetal malformation may require termination.

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Thank you